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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530077
Report Date: 07/02/2024
Date Signed: 07/02/2024 03:52:55 PM

Document Has Been Signed on 07/02/2024 03:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MAYFLOWER HOUSEFACILITY NUMBER:
365530077
ADMINISTRATOR/
DIRECTOR:		JONES JR,DR. KENNETHFACILITY TYPE:
735
ADDRESS:13634 MAYFLOWER STREETTELEPHONE:
(760) 498-6730
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 6CENSUS: 0DATE:
07/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:55 PM
MET WITH:Kenneth Jones- LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Michelle Echeverria arrived at the facility unannounced to conduct a required Annual visit. LPA was greeted and granted entrance by Licensee, Kenneth Jones. LPA toured the facility inside and outside with Licensee. LPA observed that there are currently no clients admitted to the facility.

The facility has 4 bedrooms (3 clients, 1 staff), 4 bathrooms (3 clients, 1 staff), a kitchen, pantry, dining area, family room, loft, laundry room, office, attached garage, and backyard. The facility is a specialized home pending vendorization by Inland Regional Center. LPA conducted a general overall inspection, which included, but was not limited to, the following:
Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a 84 degrees F temperature. LPA inspected clients bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. An adequate supply of linens stored in cabinets. LPA inspected client bathrooms; bathrooms were clean and appliances were operating appropriately. LPA tested the water temperature in the bathroom faucet, which tested within regulation at 116.9 degrees F. The facility is equipped with operating fire extinguisher, smoke detectors and carbon monoxide alarms. Posters such as; the personal rights, the CCL complaint poster, and disaster plans were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked. There was a designated locked storage space for client/staff files, first aid kit and medication. The facility had emergency supplies for future clients. There are no pools, bodies of water, firearms or ammunition. Overall, the facility is clean, in good repair, and operating in safe conditions for future clients in care.
Yards/Outside:
One shaded patio furniture for outdoor seating along with a mini golf set up observed. Side gate with self-latching handle on the right side of the house that leads into the backyard. All outdoor pathways were free of obstructions.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MAYFLOWER HOUSE
FACILITY NUMBER: 365530077
VISIT DATE: 07/02/2024
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Food Service: Non-perishable and perishable food supply is sufficient for future clients in care. Dishes, cups, and utensils were also stored properly.

Record Review: LPA reviewed the licensee's file for First Aid/CPR certification, criminal record clearance, training's, and health screenings. Client files were not reviewed due to a 0 census.

No deficiencies were cited during this visit. An exit interview was conducted where this report LIC809 and LIC809C were provided to Licensee, Kenneth Jones.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC809 (FAS) - (06/04)
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